Health Information Management

Scheduled care in the ED

APCs Insider, April 23, 2004

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QUESTION: When we have patients coming to the ED for scheduled care, such as IV antibiotics, should the nurses add an E/M charge to the visit? The ED physician typically does not see these patients, but the nurse obtains a set of vitals, flushes the line, starts the medication, observes the patient, and documents including some type of discharge instructions. The patient is charged a fee for the IV therapy, but what about the nursing care involved?

ANSWER: Patients seen in the ED are not typically scheduled in advance. However, some facilities must use the ED to accommodate after-hours patients. In other instances, the ED may accommodate overflow clinic patients or may be primarily responsible for administering minor procedures in the absence of a clinic. When patients are seen in the ED for a scheduled procedure, they must have a valid order for services. The patient should be registered as a clinic patient because his or her visit is not deemed an emergency. Medical-necessity rules apply and the hospital should screen the procedure and diagnosis. 
Because the patient is presenting to the ED for services, Emergency Medical Treatment and Active Labor Act (EMTALA) regulations apply. The facility may either perform an EMTALA screening for these patients or have patients sign a document indicating they are not there for emergency services.
The Centers for Medicare & Medicaid Services (CMS) is aware that nursing services, supplies, and space are provided to the patient during a procedure. When APCs were designed, CMS considered these costs in the reimbursement calculation. This means that the reimbursement for procedures such as IV infusion (Q0081) include the observation time, vital signs monitoring, supplies, and other resources associated with providing this service. It would be inappropriate to charge an E/M visit charge in addition to the procedure charge.

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